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Position Summary

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members.
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care.
Communicates with providers and other parties to facilitate care/treatment.
Identifies members for referral opportunities to integrate with other products, services, and/or programs.
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Typical office working environment with productivity and quality expectations.
Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
Sedentary work involving periods of sitting, talking, listening.
Work requires sitting for extended periods, talking on the telephone, and typing on the computer.
Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
Effective communication skills, both verbal and written.

Required Qualifications

2+ years of experience as a Registered Nurse in an adult acute care/critical care setting.
Must have active current and unrestricted RN licensure in the state of residence.

Preferred Qualifications

Education

Technical and Logistical Requirements:

Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
Future Growth: Openness to learning new skills in the future as the workplace environment evolves.

Work from Home Requirements

You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 50 Mbps download and 5 Mbps upload.
A quiet, secure, and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
The company will provide equipment (keyboard, monitor, computer, headset, etc.).

Anticipated Weekly Hours

Time Type

Pay Range

Benefits

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Utilization Management Registered Nurse

Skills